HospitalInspections.org

Based on review of facility documents, medical records, and staff interview (EMP), it was determined the facility failed to protect and promote the rights of each patient and provide a care in a safe setting by failing to ensure the psychiatrist, program manager, nurse manager and Art Therapy/Recreational Therapy/Occupational Therapy/Physical Therapy participated in patient treatment planning in eight of 12 medical records reviewed, failing to provide a copy of the treatment plan to the patient for four of 12 medical records reviewed, failing to individualize treatment plans for six of 12 medical records reviewed, and failing to ensure the psychiatrist developed treatment plan interventions for five out of 12 medical records reviewed (A0130); by failing to ensure patients had a visual check at random intervals not to exceed 15 minutes and the facility failed to complete event reports for observations not documented within the 15 minute interval for five out of 12 medical records reviewed (A0144); failing to develop and implement a restraint treatment plan for one of 12 restraint medical records reviewed (A0166); by failing to ensure a debriefing was completed between the patient and the psychiatrist within 24 hours of the termination of a restraint for six of 12 medical records reviewed (A0167); and by failing to ensure a physician's order was obtained for restraints in two of 12 medical records reviewed (A0168).

Findings include:

Review on July 6, 2017, of facility policy, "Patient's Bill of Rights and Responsibilities," dated last revised August 2016, revealed "As a patient of this hospital, or as a family member or guardian of a patient at this hospital, we want you to know the rights you have under federal and Pennsylvania state law as soon as possible in your hospital stay. We are committed to honoring your rights, and want you to know that by taking an active role in your health care, you can help hospital caregivers meet your needs as a patient or a family member. That is why we ask that you and your family share with us certain responsibilities. entering a psychiatric treatment facility can be a difficult step for both patients and families. Know what to expect can help reduce anxiety. That is why First Hospital has developed these guidelines. Your Rights ... As our patient, you have the right to safe, respectful, and dignified care at all times. You will receive services and care that are medically suggested and within the hospital's services, its stated mission, and required law and regulation. ... Care Delivery You have the right to. ... Receive care in a safe setting free from any form of abuse, harassment, or neglect. Receive kind, respectful, safe quality care delivered by skilled staff. ... Receive efficient and quality care with high professional standards that are continually maintained and reviewed. ..."

Cross reference:
482.13(b)(1) Patient Rights: Participation in Care Planning
482.13(c)(2) Patient Rights: Care in a Safe Setting
482.13(e)(4)(i) Patient Rights: Restraint or Seclusion
482.13(e)(4)(ii) Patient Rights: Restraint or Seclusion
482.13(e)(5) Patient Rights: Restraint or Seclusion

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the psychiatrist, program manager, nurse manager and Art Therapy/Recreational Therapy/Occupational Therapy/Physical Therapy participated in patient treatment planning in eight of 12 medical records reviewed (MR1, MR2, MR4, MR5, MR6, MR7, MR11, MR12); failed to provide a copy of the treatment plan to the patient for four of 12 medical records reviewed (MR2, MR5, MR7, MR9); failed to individualize treatment plans for six of 12 medical records reviewed (MR1, MR2, MR5, MR6, MR11, MR12); and failed to ensure the psychiatrist developed treatment plan interventions for five of 12 medical records reviewed (MR1, MR2, MR8, MR9, MR10.)

Findings include:

Review on June 30, 2017, of the facility policy "Treatment Planning," dated last revised February 2016, revealed "Policy: The attending psychiatrist will lead the treatment team in developing each patient's treatment plan based on a thorough assessment of the patient's biophysical, psychological, psychosocial, environmental, self care, educational, and aftercare planning needs. A Master Treatment Plan will be completed by the multidisciplinary treatment team within 72 hours of admission and approved by the attending psychiatrist. The treatment plan will be reviewed and updated as needed, but no less than once a week and any changes will be documented on the plan. The Master Treatment Plan must be reviewed with the patient and/or his family or legal guardian and signed and dated within 72 hours of admission. Any changes to the treatment plan must be shared with the patient/family and noted in the progress notes, by the social service representative. The multidisciplinary treatment planning process incorporates the plan of care for each discipline, thereby eliminating the need for separate planning documents for any discipline. Purpose: 1. To identify the patient's clinical needs and problems and provide a vehicle for continuous reassessment. 2. To establish a mechanism for interdisciplinary collaboration concerning identified problems, priorities, goals and interventions. 3. To identify a multidisciplinary clinical approach toward meeting established patient goals and to assure a consistent approach among providers. 4. To establish a mechanism to review the proposed plan of care with the patient and family (if appropriate) and to gain their cooperation and involvement, as appropriate. ... Procedure: ... B. Master Treatment Plan: 1. A Master Treatment Plan based on the assessment of the patient's presenting problems, physical health, emotional status and behaviors identified by clinical assessments completed in the first 72 hours of treatment, will be developed within 72 hours of admission. 2. Problems will be identified on the Master Treatment Plan as Active, Monitored, or Deferred. Active Problems are those identified/prioritized and will be the focus of care during the hospitalization. Each active problem will have a specific individualized problem sheet identifying goals and objectives to address the problem. ... 6. The specific interventions to help the patient meet the expected outcomes will be listed and will include the therapeutic modality to be provided, by whom, and frequency. 7. The Patient Care Coordinator (or other team member specified by the team on the care plan) will explain the treatment plan to the patient and family/significant other as appropriate. The explanation will be given in easily understood language and the Patient Care Coordinator or therapist will seek the patient's agreement with the plan and specified goals for treatment and the plan will be signed by the patient/family/guardian. In the event that the patient is unable to understand the treatment plan content, the Patient Care Coordinator or therapist will document such on the treatment plan. If the patient consents, the treatment plan may be reviewed with the family or legal guardian. This process will be documented on the Master Treatment Plan. 8. If the patient disagrees with the specified goals or planned interventions, the Patient Care Coordinator or therapist will discuss this disagreement with the treatment team and encourage the patient to discuss the disagreement with the attending psychiatrist. Resolution of the disagreement will be incorporated into the patient's ongoing treatment. Patients who have continued disagreement will be referred to the formal grievance process. C. Weekly Treatment Plan Update: ...3. The assigned therapist will review the Treatment Plan Update with the patient, parent, or guardian and seek their agreement with the plan."

Review on June 30, 2017, of the facility's "Treatment Plan Training Module," no revision date, revealed "Treatment Planning is one of the most important tools to utilize when attempting to engage a Patient in treatment. ... Joint Commission PC.01.03/01 this is where the treatment planning starts. Goals are to be individualized based on needs identified in the assessment. ... Social Service responsibilities in the Master Treatment Plan: Master Problem List Assets/Limitations (add based on Social Service Assessment) Admitting Diagnosis (from the psychiatric evaluation) Legal Status Discharge/Continuing Care Plan MTP Patient/Family involvement Treatment Team Signatures Any additional Problem Sheets ... Interventions: Methods [and] Modalities Interventions (the identified actions taken by each discipline to help the patient reduce the behaviors/symptoms). Interventions involve all treatment modalities, activities, specific groups, and services rendered to the patient and represent all disciplines. Interventions and modalities are stated in specific terms, to include type, frequency and duration. ... It is essential to specify who is responsible for intervention by discipline. ... Every discipline needs to include, at minimum, one write-in intervention (by checking the box and writing in the specific, individualized patient-focused intervention. ... Treatment Team Participant Signature/Discipline/Date/Time All of the individuals who participate in the Interdisciplinary Treatment Team Meeting must sign, date and time the form. Each member of the treatment team must include his/her discipline along with their signature. The patient, patient's family member and/or significant other are asked to sign the form after it has been reviewed with them. If the patient refused to sign the form, staff writes in the reason for the refusal. If the family member/SO signs the form, check whether or not the individual is the patients' DPOA/guardian. Check off the box indicating whether or not the patient/family member/SO were present at the Treatment Team Meeting. If the patient and/or family member/SO were present have each of them sign their names on the bottom of the form. If they weren't present write the reason they were not present. Providing Patient Driven Care Each staff member should review the completed Interdisciplinary Master Treatment Plan along with the ITP Problem Sheets on a regular basis in order to make sure they know what the short and long term goals are as well as the specific interventions they should be providing. ..."

1) Review on June 30, 2017, of MR1 revealed a Master Treatment Plan initiated on June 18, 2017. There was no documentation of participation by the psychiatrist or program director, as there was no psychiatrist signature or program director signature on the Master Treatment Plan. The Master Treatment Plan Meeting Update was completed on June 26, 2017. There was no documentation of participation by the psychiatrist, as there was no psychiatrist signature on the update.

Review on June 30, 2017, of MR2 revealed a Master Treatment Plan initiated on June 26, 2017. There was no documentation of participation by the psychiatrist, nurse manager, or program director, as there was no psychiatrist signature, nurse manager signature, or program director signature.

Review on July 6, 2017, of MR5 revealed a Master Treatment Plan initiated on January 24, 2017. There was no documentation of participation by nursing or the program director, as there was no nurse's signature or program director signature. There was a Master Treatment Plan Meeting Update on February 8, 2017. There was no documentation of participation by the psychiatrist, as there was no psychiatrist signature.

Review on July 6, 2017, of MR6 revealed a Master Treatment Plan initiated on February 2, 2017. There was no documentation of participation by the nurse manager or program director, as there was no nurse manager signature or program director signature. There were Master Treatment Plan Meeting Updates on February 15, 2017, February 22, 2017, and March 1, 2017. There was no documentation of participation by AT/RT/OT/PT (Art Therapy/Recreational Therapy/Occupational Therapy/Physical Therapy), as there was no AT/RT/OT/PT signature.

Review on July 6, 2017, of MR11 revealed a Master Treatment Plan initiated on June 17, 2017. The time of the meeting was not documented. There was no documentation of participation by the program director, as there was no program director signature. There was a Master Treatment Meeting Update on June 26, 2017. There was no documentation of participation by nursing, as there was no nurse's signature on the update. There was a Master Treatment Meeting Update on July 3, 2017. There was no documentation of participation by the psychiatrist and nursing, as there was no psychiatrist signature or nurse's signature.

Review on July 6, 2017, of MR12 revealed a Master Treatment Plan initiated on January 31, 2017. There was no documentation of participation by the nurse manager or program director, as there was no nurse manager signature or program director signature. There was a Master Treatment Plan Meeting Update dated February 6, 2017. There was no documentation of patient participation, as there was no patient signature. There was no documentation the patient refused or unable to sign the treatment plan. There was a Master Treatment Plan Meeting Update on February 13, 2017. There was no documentation of participation by the patient and nursing, as there was no patient signature or nurse's signature. There was a Master Treatment Plan Meeting Update on February 20, 2017. There was no documentation of participation by the patient and nursing, as there was no patient signature or nurse's signature.

Interview on July 6, 2017, with EMP3 confirmed there was no documentation of participation by the treatment team members and/or patients for MR1, MR2, MR5, MR6, MR11, MR12, as there were no signatures by these individuals on the facility's treatment plans.

Review of MR4 on July 5, 2017, revealed a Master Treatment Plan Initial Data Form initiated on June 26, 2017. The problems identified on this initial treatment plan include schizophrenia disorder, depression, anxiety, and the patient was a danger to self and others. The Master Treatment Plan Initial Data Form revealed no participation by AT/RT/OT/PT and the Program Director, as there was no AT/RT/OT/PT signature or program director signature.

Interview with EMP3 on July 5, 2017, at approximately 9:45 AM confirmed MR4's Master Treatment Plan Initial Data Form on June 26, 2017, did not contain signatures for AT/RT/OT/PT or the Program Director.

Review of MR7 on July 5, 2017, revealed a Master Treatment Plan Initial Data Form initiated on May 30, 2017. The problems identified on this initial treatment plan include suicidal thoughts, depression and anxiety. There was no documentation of participation by the psychiatrist or program director, as there was no psychiatrist signature or program director signature.

Interview with EMP3 on July 5, 2017, at approximately 10:15 AM confirmed MR7's Master Treatment Plan Initial Data Form dated May 30, 2017, did not contain signatures for the psychiatrist or the program director. EMP3 confirmed the psychiatrist was the director of the treatment team and was responsible for implementing and reviewing the individualized treatment plans.

2) Review on July 5, 2017, of the facility's "BH [behavioral health] Master Treatment Plan Initial Data Form," last revised February 2015, revealed the Patient/Guardian Statement area directing facility staff to indicate by a Yes or a No if the patient received a copy of the Treatment Plan Review.

Review on July 5, 2017, of the facility's "BH Master Treatment Plan Meeting Update" form, last revised June 2014, revealed an area in the Patient/Guardian Statement area directing facility staff to indicate by a Yes or a No if the patient received a copy of the Treatment Plan Review.

Review of MR2 on July 5, 2017, revealed a BH Master Treatment Plan Initial Data Form dated June 26, 2017. There was no documentation facility staff provided the patient with a copy of the treatment plan.

Interview with EMP3 on July 5, 2017, at approximately 10:30 AM confirmed MR2's Master Treatment Plan Initial Data Forms dated June 26, 2017, did not contain documentation the facility staff provided the patient with a copy of the treatment plan.

Review of MR5 on July 5, 2107, revealed a BH Master Treatment Plan Initial Data Form dated January 26, 2017. There was no documentation the facility staff provided the patient with a copy of the treatment plan. There was a BH Master Treatment Plan Initial Data Form dated February 10, 2017. There was no documentation the facility staff provided the patient with a copy of the treatment plan.

Interview with EMP3 on July 5, 2017, at approximately 10:00 AM confirmed MR5's Master Treatment Plan Initial Data Forms dated January 26, 2017, and February 10, 2017, did not contain documentation the facility staff provided the patient with copies of the treatment plans.

Review of MR7 on July 5, 2017, revealed a Master Treatment Plan Initial Data Form dated May 30, 2017. There was no documentation the facility staff provided the patient with a copy of the treatment plan. There were BH Master Treatment Plan Meeting Update Forms dated June 13, 2017, June 21, 2017, and June 30, 2017. There was no documentation the facility staff provided the patient with copies of treatment plan updates.

Interview with EMP3 on July 5, 2017, at approximately 10:15 AM confirmed MR7's BH Master Treatment Plan Meeting Update Forms dated June 13, 2017, June 21, 2017, and June 30, 2017, did not contain documentation the facility staff provided the patient with copies of the treatment plan and the updates.

Review of MR9 on July 5, 2017, revealed a BH Master Treatment Plan Meeting Update Form dated June 30, 2017. There was no documentation the facility staff provided the patient with a copy of the treatment plan.

Interview with EMP3 on July 5, 2017, at approximately 10:20 AM confirmed MR9's BH Master Treatment Plan Meeting Update Form dated June 30, 2017, did not contain documentation the facility staff provided the patient with a copy of the treatment plan.

3) Review on June 30, 2017, of MR1 revealed a Master Treatment Plan initiated on June 18, 2017. The problem identified on the initial assessment was suicidal ideations with a plan. There were no individualized patient-focused interventions completed by the physician, nursing, or social work.

Review on July 6, 2017, of MR5 revealed a Master Treatment Plan dated initiated January 24, 2017. The problem identified on the initial assessment was risk of violence. There were no individualized patient-focused interventions completed by the physician, nursing, or therapy.

Review on July 6, 2017, of MR6 revealed a Master Treatment Plan dated initiated February 2, 2017. The problem identified on the initial assessment was hallucinations. There were no individualized patient-focused interventions completed by the physician, nursing, or therapy.

Review on July 6, 2017, of MR11 revealed a Master Treatment Plan dated initiated June 17, 2017. The problem identified on the initial assessment was depression. There were no individualized patient-focused interventions completed by the physician, nursing, or therapy.

Review on July 6, 2017, of MR12 revealed a Master Treatment Plan dated initiated January 31, 2017. The problems identified on the initial assessment were potential for violence and impulsivity. There were no individualized patient-focused interventions completed by the physician, nursing, therapy, and social work.

Interview on July 6, 2017, with EMP3 confirmed MR1, MR5, MR6, MR11, MR12 did not include individualized patient-focused interventions by all disciplines.

Review on June 30, 2017, of MR2 revealed a Master Treatment Plan dated initiated June 26, 2017. The problems identified on the initial assessment was suicidal ideation with recent attempt. There were no individualized patient-focused interventions completed by the physician, nursing, therapy, and social work. There was documentation in nursing interventions for a pre-printed intervention selected "Provide patient / family education about sundowning associated with disease process."

Interview on July 6, 2017, with EMP3 and EMP4 confirmed MR2 did not include individualized patient-focused interventions by every discipline. EMP3 and EMP4 confirmed there was documented intervention in MR2 to provide the patient with education related to sundowning. EMP3 and EMP4 revealed this intervention did not apply to this adolescent patient and was meant for patients with Alzheimer's.

4) Review on June 30, 2017, of MR1 revealed a Master Treatment Plan dated initiated on June 18, 2017. There was no documentation the attending psychiatrist developed treatment plan intervention(s) for the patient.

Review on June 30, 2017, of MR2 revealed a Master Treatment Plan dated initiated on June 26, 2017. There was no documentation the attending psychiatrist developed treatment plan intervention(s) for the patient.

Interview on June 30, 2017, with EMP3 confirmed there was no documentation the attending psychiatrist developed treatment plan interventions for MR1 and MR2.

Review of MR8 on July 5, 2017, revealed a Master Treatment Plan dated June 30, 2017. There was no documentation the attending psychiatrist developed treatment plan intervention(s) for the patient.

Review of MR9 on July 5, 2017, revealed a Master Treatment Plan dated June 12, 2017. There was no documentation the attending psychiatrist developed treatment plan intervention(s) for the patient.

Review of MR10 on July 5, 2017, revealed a Master Treatment Plans dated March 8, 2017 and March 24, 2017. There was no documentation the attending psychiatrist developed treatment plan intervention(s) for the patient.

Interview with EMP5 on July 5, 2017, at approximately 11:00 AM confirmed there was no documentation the attending psychiatrist developed treatment plan interventions for MR8, MR9 and MR10.

Cross reference:
482.13(c)(2) Patient Rights: Care in Safe Setting

Continuing deficiency cited during the Validation survey November 9, 2016.

Based on review of facility documents, medical records (MR), and staff interview it was determined the facility failed to ensure patients had a visual check at random intervals not to exceed 15 minutes and the facility failed to complete event reports for observations not documented within the 15 minute interval for five out of 12 medical records reviewed (MR1, MR2, MR4, MR7 and MR8).

In accordance with 42 C.F.R. Part 489.3 this deficiency constitutes Immediate Jeopardy and is a situation in which noncompliance with the requirement of participation has caused, or is likely to cause, serious injury, harm, impairment or death.

Findings include:

Review on July 6, 2017, of facility policy, "Patient's Bill of Rights and Responsibilities," dated last revised August 2016, revealed "As a patient of this hospital, or as a family member or guardian of a patient at this hospital, we want you to know the rights you have under federal and Pennsylvania state law as soon as possible in your hospital stay. Your Rights. ... As our patient, you have the right to safe, respectful, and dignified care at all times. ... Care Delivery You have the right to. ... Receive care in a safe setting free from any form of abuse, harassment, or neglect. Receive kind, respectful, safe quality care delivered by skilled staff. ... Receive efficient and quality care with high professional standards that are continually maintained and reviewed. ..."

Review on June 30, 2017, of facility policy, "Patient Observation," dated revised February 2017, revealed "Policy: Patient observation by clinical staff is an important component to twenty-four hour inpatient care. It is one way to meet the safety functions of an inpatient milieu environment, allows the patient to feel safe, and provides a visual observation and documentation of the observation for each patient at First Hospital. Purpose: 1. To ensure physical safety of all patients. 2. To identify potential problems with specific patient (either physical or mental status change). 3. To convey to patients a feeling of safety. 4. To ensure the safety of the environment and potential situations. 5. To ensure the safety of staff and visitors. Procedure. 1. Within fifteen minute visual checks will be completed for all patients. The visual checks should be at random intervals but not to exceed 15 minutes. 2. For all visual checks each time, staff must see the patient. It is not acceptable to i.e. knock on the bathroom door and wait for an answer from the patient. Let the patient know you must see them and visually observe. 3. For all visual checks, each time, staff must determine the patient is breathing (when asleep, for example, check for breathing by observing chest movement). ...8. Documentation is completed at the time of the visual observation on the patient observation record. In the unlikely event an observation was not documented with in the fifteen minute interval, an Event report needs to be completed. Note: there should not be any blank lines. The next time will reflect a time that is greater than fifteen minutes."

1) Review on June 30, 2017, of MR1 revealed the following: The patient was admitted on June 18, 2017, at 3:50AM. The psychiatric evaluation was completed on June 18, 2017. The initial assessment was suicidal ideation with a plan. The patient was placed on ur-close. The physician order dated June 18, 2017 at 4:30 AM was unit restriction with close observation.

Interview on June 30, 2017 with EMP4 revealed ur-close indicated q 15 (every 15) minute checks.

MR1's Patient Observation Record dated June 24, 2017 revealed the patient was visually checked at 6:00 PM, 6:20 PM, 7:00 PM, and 7:17 PM.

Interview on June 30, 2017, with EMP4 confirmed MR1's Patient Observation Record dated June 24, 2017 had documentation of visual checks at 6:00 PM and then 6:20 PM. EMP4 confirmed the visual check exceeded 15 minutes. EMP4 confirmed MR1 was visually checked at 7:00 PM and then 7:17 PM. EMP4 confirmed the visual check exceeded 15 minutes.

Interview on June 30, 2017 with EMP1 at approximately 12:40 PM revealed MR1 was disruptive during group therapy on June 29, 2017. This behavior resulted in the patient losing free time for 24 hours. During free time the patient stayed in their room.

Review on June 30, 2017, of MR1's Patient Observation Record dated June 29, 2017 revealed the patient was visually checked by a staff member at 6:05 PM, 6:20 PM, 6:35 PM, 6:50 PM, and 7:04 PM.

Interview on June 30, 2017, with EMP1 confirmed MR1's Patient Observation Record revealed MR1 was visually checked by a staff member on June 29, 2017 at 6:05 PM, 6:20 PM, 6:35 PM, and 6:50 PM.

Interview on June 30, 2017, with EMP1 revealed EMP1 reviewed the video surveillance from June 29, 2017. The surveillance video revealed the following: MR1 was at the nurses' station at 6:18 PM, returned to their room at 6:19 PM, and closed the door. At 6:38 PM, EMP14 walked into the patient's room for 16 seconds and walked out. At 7:14, EMP11 walked into MR1's room for a visual check and found MR1 sitting on the bathroom floor with the bed sheet tied around their neck and attached to the paper towel dispenser. MR1 was unresponsive. EMP1 confirmed the patient did not have a visual check by a staff member for a total of 36 minutes. EMP1 confirmed MR1's Patient Observation Record from June 29, 2017 did not match the video surveillance from June 29, 2017.

Review of MR1 on July 6, 2017 revealed a Medical Discharge Form. The documentation on the Form revealed the following: The patient was discharged on June 29, 2017 to an outside hospital. The patient was found in the bathroom unresponsive with a blanket around the neck. The patient was in the sitting position. A code was called, and cardiopulmonary resuscitation was started until EMT arrived. The spaces for the RN Signature, Date, and Time were blank.

2) Review on June 30, 2017, of MR2 revealed the patient was admitted on June 25, 2017. MR2's Patient Observation Record dated June 26, 2017 revealed the patient was observed by a staff member at 12:32 PM, 12:55 PM, 6:12 PM, 6:31 PM, 8:21 PM, 8:46 PM, 10:00 PM, 10:16 PM, 10:21 PM, and 10:41 PM.

Interview on June 30, 2017, with EMP4 confirmed MR2's Patient Observation Record dated June 26, 2017 documented the patient was checked at 12:32 PM and then 12:55 PM, 6:12 PM and then 6:31 PM, 8:21 PM and then 8:46 PM, 10:00 PM and then 10:16 PM, 10:21 PM and then 10:41 PM. EMP4 confirmed the visual check exceeded 15 minutes.

MR2's Patient Observation Record dated June 27, 2017 revealed MR2 was visually checked at 9:40 PM and then 10:00 PM.

Interview on June 30, 2017, with EMP4 confirmed MR2's Patient Observation Record dated June 27, 2017 documented the patient was checked at 9:40 PM and then 10:00 PM. EMP4 confirmed the visual check exceeded 15 minutes.

MR2's Patient Observation Record dated June 28, 2017 revealed MR2 was visually checked at 8:23 AM and then 8:46 AM. Another visual check was performed at 10:44 AM and then 11:00 AM.

Interview on June 30, 2017, with EMP4 confirmed MR2's Patient Observation Record dated June 28, 2017 revealed MR2 was visually checked at 8:23 AM and then 8:46 AM. EMP4 confirmed the visual check exceeded 15 minutes. EMP4 confirmed MR2 was checked at 10:44 AM and then 11:00 AM. EMP4 confirmed the visual check exceeded 15 minutes.

MR2's Patient Observation Record dated June 29, 2017 revealed MR2 was visually checked at 1:32 AM and then 1:50 AM. Another visual check was performed at 3:10 PM and then 3:40 PM. Another visual check was performed at 7:19 PM and then 7:45 PM.

Interview on June 30, 2017, with EMP4 confirmed MR2's Patient Observation Record dated June 29, 2017 documented the patient was checked at 1:32 AM and then 1:50 AM. EMP4 confirmed the visual check exceeded 15 minutes. EMP4 confirmed MR2 was checked at 3:10 PM and then 3:40 PM. EMP4 confirmed the visual check exceeded 15 minutes. EMP4 confirmed MR2 was checked at 7:19 PM and then 7:45 PM. EMP4 confirmed the visual check exceeded 15 minutes.

3) Review on June 30, 2017, of MR4 revealed this patient was admitted on June 24, 2017. MR4's Patient Observation Record dated June 28, 2017, revealed the patient was visually checked by a staff member at 8:11 AM, 8:31 AM, 11:14 AM and 11:33 AM.

Interview with EMP4 on June 30, 2017, at approximately 1:45 PM confirmed MR4's Patient Observation Record dated June 28, 2107, documented the patient was visually checked by a staff member on June 28, 2017, at 8:11 AM, 8:31 AM, 11:14 AM and 11:33 AM. EMP4 confirmed the staff visual checks of MR4 exceeded 15 minutes.

4) Review on June 30, 2017, of MR7 revealed the patient was admitted on May 27, 2017. MR7's Patient Observation Record dated May 27, 2017, revealed the patient was visually checked by staff at 7:15 AM, 7:28 AM, 9:27 AM and 10:00 AM.

Interview with EMP5 on June 30, 2017, at approximately 2:00 PM confirmed MR7's Patient Observation Record dated May 27, 2017, revealed the patient was visually checked by staff at 7:15 AM, 7:28 AM, 9:27 AM and 10:00 AM. EMP5 confirmed the staff visual checks exceeded 15 minutes.

MR7's Patient Observation Record dated May 28, 2017, revealed the patient was visually checked by staff at 12:26 PM, 12:45 PM, 6:13 PM and 6:30 PM.

Interview with EMP5 on June 30, 2017, at approximately 2:10 PM confirmed MR7's Patient Observation Record dated May 28, 2017, revealed the patient was visually checked by staff at 12:26 PM, 12:45 PM, 6:13 PM and 6:30 PM. EMP5 confirmed the staff visual checks exceeded 15 minutes.

MR7's Patient Observation Record dated June 4, 2017, revealed the patient was visually checked by staff at 4:05 PM, 4:28 PM, 11:13 PM and 11:34 PM.

Interview with EMP5 on June 30, 2017, at approximately 2:15 PM confirmed MR7's Patient Observation Record dated June 4, 2017, revealed the patient was visually checked by staff at 4:05 PM, 4:28 PM, 11:13 PM and 11:34 PM. EMP5 confirmed the staff visual checks exceeded 15 minutes.

MR7's Patient Observation Record dated June 5, 2017, revealed the patient was visually checked by staff at 10:00 AM, 10:21 AM, 12:13 PM, 1:13 PM, 1:38 PM and 1:58 PM.

Interview with EMP5 on June 30, 2017, at approximately 2:20 PM confirmed MR7's Patient Observation Record dated June 5, 2017, revealed the patient was visually checked by staff at 10:00 AM, 10:21 AM, 12:13 PM, 1:13 PM, 1:38 PM and 1:58 PM. EMP5 confirmed the staff visual checks exceeded 15 minutes.

5) Review on July 5, 2017, of MR8 revealed this patient was admitted on June 29, 2017. MR8's Patient Observation Record dated June 30, 2017, revealed the patient was visually checked by staff at 1:00 PM and then at 1:31 PM.

Interview with EMP4 on July 5, 2017, at approximately 10:05 AM confirmed MR8's Patient Observation Record revealed the patient was visually checked by a staff member on June 30, 2017, at 1:00 PM and then at 1:31 PM. EMP4 confirmed the staff visual checks exceeded 15 minutes.

MR8's Patient Observation Record revealed the patient was visually checked by a staff member on July 2, 2017, at 3:16 PM, 3:52 PM, 5:20 PM, 5:40 PM, 10:14 PM and 10:37 PM.

Interview with EMP4 on July 5, 2017, at approximately 10:15 AM confirmed MR8's Patient Observation Record revealed the patient was visually checked by a staff member on July 2, 2017, at 3:16 PM, 3:52 PM, 5:20 PM, 5:40 PM, 10:14 PM and 10:37 PM. EMP4 confirmed the staff visual checks exceeded 15 minutes.

A request on July 5, 2017, at approximately 3:00 PM was made to EMP8 to review the facility's event reports for the documented observations that exceeded 15 minutes on MR1, MR2, MR4, MR7 and MR8. No facility event reports were provided.

A second request on July 6, 2017, at approximately 10:45 AM was made to EMP8 to review the facility event reports for the documented observations that exceeded 15 minutes on MR1, MR2, MR4, MR7 and MR8. No event reports were provided.

Interview on July 6, 2017, at approximately 12:00 PM, with EMP6 confirmed no facility event reports were completed for the documented observations that exceeded 15 minutes on MR1, MR2, MR4, MR7 and MR8.

Cross reference:
428.13(b)(1) Patient Rights: Participation in Care Planning
482.23(b)(5) Patient Care Assignments

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to develop and implement a restraint treatment plan for one of 12 restraint medical records reviewed (MR10).

Findings include:

Review on June 30, 2017, of facility policy, "Treatment Planning," dated reviewed February 2016, revealed "Policy: The attending psychiatrist will lead the treatment team in developing each patient's treatment plan based on a thorough assessment of the patient's biophysical, psychological, psychosocial, environmental, self care, educational and aftercare planning needs. A Master Treatment Plan will be completed by the multidisciplinary treatment team within 72 hours of admission and approved by the attending psychiatrist. The treatment plan will be reviewed and updated as needed, but no less than once a week and any changes will be documented on the plan. ... Any changes to the treatment plan must be shared with the patient/family and noted in the progress notes, by the social service representative. ... 5. To provide a mechanism to monitor patient progress, to reassess the problem list. Procedure: . ...B. Master Treatment Plan: 1. A Master Treatment Plan based on the assessment of the patient's presenting problems, physical health, emotional status and behaviors identified by clinical assessments completed in the first 72 hours of treatment, will be developed within 72 hours of admission. ..."

Review of MR10 on July 5, 2017, revealed a physician order dated March 8, 2017, at 10:40 AM instructing nursing staff to apply four-point restraints on the patient for up to one hour for the protection of self and others. There was a second physician order dated March 8, 2017, at 11:40 AM instructing nursing staff to apply four-point restraints on the patient for up to one hour for the protection of self and others.

Review on July 5, 2017, of MR10's Master Treatment Plans dated March 7, 2017, March 10, 2017, and March 22, 2017, revealed no documentation the facility's treatment team developed a treatment plan addressing the patient's restraints.

Review on July 5, 2017, of MR10's Master Treatment Plan Meeting Update forms dated March 16, 2017, March 21, 2017, March 28, 2017, and April 4, 2017, revealed no documentation the facility's treatment team updated MR10's master treatment plan to address the patient's restraints.

Interview with EMP5 and EMP7 on July 5, 2017, at approximately 2:45 PM confirmed the physicians' orders for restraining MR10; the facility's treatment team did not develop a restraint treatment plan for the restraints; and the facility's treatment team did not update the patient's master treatment plan to address the restraints. EMP5 confirmed it was the expectation of the facility's treatment team to ensure the patient's master treatment plan and the master treatment plan meeting updates reflected all the treatments and interventions the patient encountered during their stay at the facility.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure a debriefing was completed between the patient and the psychiatrist within 24 hours of the termination of a restraint for six of 12 medical records reviewed (MR2, MR3, MR5, MR6, MR10, and MR12.)

Findings include:

Review on July 6, 2017, of facility policy "Restraint and Locked Seclusion," dated last revised February 4, 2016, revealed "Policy: Restraints and locked seclusion will be used only in clinically justified situations in which there is an imminent risk of a patient physically harming him/herself or others. ... Philosophy: In order to provide the highest quality of patient care and focus on the patient's well being, First Hospital is committed to fostering an atmosphere which limits restraint and locked seclusion. ... IV. Debriefing and Review of Incident: A. Review of incident between consumer and psychiatrist: Within 24 hours of the termination of the locked seclusion and/or restraint, a review of the incident leading to restraint and/or locked seclusion will occur between the patient and the psychiatrist. ..."

Review on July 6, 2017, of MR5 revealed an order for four-point restraints dated January 31, 2017. There was no documentation a debriefing was completed between the patient and the psychiatrist within 24 hours of the termination of the four-point restraint.

Review on July 6, 2017, of MR6 revealed an order for supine extension, a non mechanical restraint, not to exceed 10 minutes dated February 7, 2017. There was no documentation a debriefing was completed between the patient and the psychiatrist within 24 hours of the termination of the restraint.

Review of MR10 on July 6, 2017, revealed a physician order dated March 8, 2017, for four-point restraints. There was no documentation a debriefing was completed between the patient and the psychiatrist within 24-hours of termination of the four-point restraints as required by facility policy.

Interview with EMP5 on July 6, 2017, at approximately 2:30 PM confirmed MR10's physician order for four-point restraints on March 8, 2017. EMP5 confirmed there was no documentation a debriefing between the patient and the psychiatrist within 24-hours of termination of the four-point restraints as required by facility policy.

Review on July 6, 2017, of MR12 revealed an order for locked seclusion dated February 4, 2017. There was no documentation a debriefing was completed between the patient and the psychiatrist within 24 hours of the termination of the locked seclusion. There was an order for locked seclusion dated February 6, 2017. There was no documentation a debriefing was completed between the patient and the psychiatrist within 24 hours of the termination of the locked seclusion.

Interview on July 6, 2017, with EMP10 confirmed there was no documentation in MR5 and MR6 that debriefings between the patient and the psychiatrist were completed within 24 hours of the termination of the restraints.

Interview on July 6, 2017, with EMP4 confirmed there was no documentation in MR12 that a debriefing between the patient and the psychiatrist was completed within 24 hours of the termination of locked seclusion.

Review on July 6, 2017, of MR2 revealed an order for non-mechanical restraints for up to 10 minutes and five-point restraints dated June 29, 2017. There was no documentation a debriefing was completed between the patient and the psychiatrist within 24 hours of the termination of the restraints.

Interview on July 6, 2017, with EMP4 confirmed there was no documentation in MR2 that a debriefing between the patient and the psychiatrist was completed within 24 hours of the termination of the restraints.

Review on July 6, 2017, of MR3 revealed an order for four-point restraints dated March 18, 2017. There was no documentation a debriefing was completed between the patient and the psychiatrist within 24 hours of the termination of the four-point restraint. There was an order for a non-mechanical hold not to exceed 10 minutes dated April 19, 2017. There was no documentation a debriefing was completed between the patient and the psychiatrist within 24 hours of the termination of the non-mechanical hold. There was an order for non-mechanical hold not to exceed 10 minutes dated April 18, 2017. There was no documentation a debriefing was completed between the patient and the psychiatrist within 24 hours of the termination of the non-mechanical hold. There was an order for locked seclusion dated May 3, 2017. There was no documentation a debriefing was completed between the patient and the psychiatrist within 24 hours of the termination of the locked seclusion. There was an order for four-point restraints dated May 29, 2017. There was no documentation a debriefing was completed between the patient and the psychiatrist within 24 hours of the termination of the four-point restraint. There was an order for four-point restraints dated June 20, 2017. There was no documentation a debriefing was completed between the patient and the psychiatrist within 24 hours of the termination of the four-point restraint.

Interview on July 6, 2017, with EMP9 confirmed there was no documentation in MR3 that a debriefing between the patient and the psychiatrist was completed within 24 hours of the termination of the restraint on March 18, 2017, April 19, 2017, April 18, 2017, May 29, 2017, and June 20, 2017.

Interview on July 6, 2017, with EMP9 confirmed there was no documentation in MR3 that a debriefing between the patient and the psychiatrist was completed within 24 hours of the termination of the locked seclusion on May 3, 2017.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure a physician's order was obtained for restraints in two of 12 medical records reviewed (MR2 and MR3).

Findings include:

Review on July 6, 2017, of the facility policy "Restraint and Locked Seclusion," last reviewed February 4, 2017, revealed "Policy: Restraints and locked seclusion will be used only in clinically justified situations in which there is an imminent risk of a patient physically harming him/herself or others. ... The restraint and seclusion policies will describe how First Hospital: a) Protects and preserves the patient's rights, dignity, and well-being during use; b) Bases use on the patient's assessed needs; c) Makes decisions about least restrictive methods; d) Assures safe application and removal, as early as possible, by competent staff; e) Monitors and reassesses the patient during use; f) Assesses patient's readiness for discontinuation g) Meets patient needs during use; h) Time-limited orders; i) Limits individual orders to licensed independent practitioners; j) Documents in the medical record when restraints or locked seclusion is used. ... Definitions: I. Restraints A. Defined per CMS 42 CFR 482.13 (e)(1) as (A) any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. Restraint is considered involuntary and requires individual specific physician orders. ... II. Locked Seclusion Defined per CMS 42 CFR 482.13 (e) (1) (ii) as the involuntary confinement of a patient alone in a room or area where the patient is physically prevented from leaving. Defined per OMHSAS-02-01- seclusion is restricting child/adolescent/adult in a locked room, and isolating the person from any personal contact. The term 'locked room' includes any type of door locking device such as a key lock, spring lock, bolt lock, foot pressure lock or physically holding the door closed, preventing the individual from leaving the room. Locked seclusion requires individual specific orders. ... II. Restraints ... D. In an emergency situation, if a physician is not present due to extenuating circumstances, a registered nurse is permitted to initiate the use of restraints for the protection of the patient and/or others, and the registered nurse must immediately contact the physician on duty/on call and obtain a verbal order. ... III. Locked Seclusion ... D. In an emergency situation, if a physician is not present due to extenuating circumstances, a registered nurse is permitted to initiate the use of locked seclusion for the protection of the patient and/or others, and the registered nurse must immediately contact the physician on duty/on call and obtain a verbal order. ..."

Review on July 6, 2017, of the facility policy "Verbal/Telephone Orders," last reviewed January 2017, revealed "Safety is the overriding principle in accepting verbal or telephone orders. Verbal and telephone orders have a higher potential for errors as these orders can be misheard, misinterpreted and /or mis-transcribed. Verbal orders/telephone orders are to be used infrequently and never for the convenience of the physicians. Policy 1. Verbal and telephone orders may be accepted by a registered nurse or LPN for emergencies and when it is impossible or impractical for the physician to write them. Procedure 1. The physician identifies self, specifies the patient's name, and communicates the order to a RN/LPN. 2. The receiver (RN/LPN): documents the order immediately on the physician's order form including the specific order, date, time, physician's name, and the RN/LPN signature ... 3. The order must be authenticated as per Medical Staff bylaws."

Review on July 6, 2017, of the facility's "Rules and regulations of the Medical Staff First Hospital and Choices," last reviewed June 2017, revealed "I. Purpose of Rules and Regulations The Purpose of the Rules and Regulations of the Medical Staff of First Hospital Wyoming Valley and CHOICES (referred to as "Hospital") is to further clarify the standards of professional practice and medical record documentation which govern the Medical Staff. A. The Medical Staff abides by all policies and procedures of the facility. Special reference is given to the administrative and departmental policies and procedures which relate directly to standards for professional practice and patient and staff safety. ... VIII. Physician Orders A. All orders must be given and/or written by fully privileged physicians. All orders must include date and time (a.m. or p.m.) when they are written. Verbal orders may only be received by a registered nurse and must be countersigned, dated, and timed by a fully privileged physician within twenty-four (24) hours. Verbal physician orders will be authenticated within twenty-four (24) hours by the physician's co-signature, date, and time of the signature. Verbal physician's orders for restraint and locked seclusion will be authenticated within twenty-four (24) hours by the physician's co-signature, date, and time of the signature. ..."

Review on July 6, 2017, of MR2 revealed a telephone order for restraints dated June 29, 2017. There was no documentation in MR2 the physician authenticated the telephone order.

Review on July 6, 2017, of MR3 revealed a telephone order for restraints dated April 18, 2017. There was no documentation in MR3 the physician authenticated the telephone order. There was a telephone order for restraints dated April 19, 2017. There was no documentation in MR3 the physician authenticated the telephone order. There was a telephone order for locked seclusion dated May 3, 2017 and the telephone order was authenticated by the physician May 11, 2017.

Interview on July 6, 2017, at approximately 12:00 PM with EMP9 confirmed there was no documentation in MR2 the physician authenticated the telephone order for restraints dated June 29, 2017. EMP9 confirmed there was no documentation in MR3 the physician authenticated the telephone orders for restraints dated April 18, 2017 and April 19, 2017. EMP9 confirmed the physician did not authenticate the telephone order of May 3, 2017, for locked seclusion within 24 hours in MR3.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure the Performance Improvement Committee meeting minutes reflected accurate and relevant measurable data.

Findings include:

Review on July 6, 2107, of the facility "Performance Improvement Program 2017," no approval date, revealed "... III. Purpose: The Performance Improvement Program is designed to provide a systematic and organized mechanism to promote safe and quality patient care and services. Through an integrated, interdisciplinary process, patient care and services shall be continuously monitored and evaluated to promote optimum outcomes. The organization has the responsibility to design, measure, assess, and improve performance and patient safety. Ultimate authority and accountability for the quality and safety of patient care and services lies with the Governing Board and is delegated through the Performance Improvement Program to the Medial Staff, Administration and staff of the hospital. ... VIII. Performance Improvement Committee the Performance Improvement Committee is the multidisciplinary body charged by the Governing Board with oversight of all aspects of the Performance Improvement Program throughout the facility. The Council accomplishes the oversight function through: Implementing a systematic, continuous improvement process. Receiving recommendations from various sources regarding Performance Improvement efforts. Integrating findings and outcomes of reviews conducted by Medical Staff Committees. Evaluating and prioritizing problems and identified opportunities to improve. Analyzing and comparing data with external sources when available. Chartering and facilitating Performance Improvement Teams and projects. Acting on reports from Performance Improvement Team activities. Facilitating communication of the team progress and improvements throughout the organization. Evaluating corrective actions and confirms that they resulted in improvements. Maintaining a permanent record of its proceedings. ..."

Review on July 6, 2017, of the facility's "Performance Improvement Committee" meeting minutes dated July 20, 2016, revealed the facility audited 38 charts for June 2016. A decline in improvement was noted in several areas. There was no documentation in the facility's Performance Improvement Committee meeting minutes indicating what areas the facility identified with a decline in improvement.

Interview with EMP1 on July 6, 2017, at approximately 10:00 AM confirmed there was no documentation in the facility's Performance Improvement Committee meeting minutes for July 20, 2016, indicating what areas the facility identified with a decline in improvement.

Review on July 6, 2017, of the facility's "Performance Improvement Committee" meeting minutes dated August 24, 2016, revealed 44 charts were audited for July 2016. Overall, the psychiatric evaluations completed in 24 hours averaged 93%. The general documentation averaged higher at 98% for July. Nursing Progress notes averaged 90% while physician progress notes averaged 95%. There was no documentation indicating the data the facility used to evaluate general documentation or criteria the facility used to evaluate the nursing and physician progress notes.

Interview with EMP1 on July 6, 2017, at approximately 10:05 AM confirmed the Medicare Chart Audit for August 24, 2016. EMP1 confirmed there was no documentation indicating the data the facility used to evaluate general documentation or criteria the facility used to evaluate the nursing and physician progress notes.

Review on July 6, 2017, of the facility's "Performance Improvement Committee" meeting minutes dated January 18, 2017, revealed 38 charts were audited. A decline in improvement was noted in several areas. There were no trends noted. There was no documentation in the facility's Performance Improvement Committee meeting minutes indicating what areas the facility identified with a decline in improvement.

Interview with EMP1 on July 6, 2017, at approximately 10:15 AM confirmed there was no documentation in the facility's Performance Improvement Committee meeting minutes for January 18, 2017, indicating what areas the facility identified with a decline in improvement.

Based on review of facility documents, personnel files (PF) and staff interview (EMP), it was determined the facility failed to follow their established method of new employee orientation and initial competency for one of six personnel files reviewed (PF1).

Findings include:

Review on July 6, 2017, of the facility's "Department Orientation and Initial Competency Assessment (DOICA) Mental Health Technician" no review date, revealed "This DOICA indicates initial competency of the above employee and is to be completed within 90 days of hire. Method of Assessment O = Observation: Direct observation by a supervisor, designated evaluator, preceptor or team member D = Demonstration: Return demonstration by the employee, i.e. during a department in-service, etc. C = Cognitive: Written and/or verbal demonstration of knowledge, i.e. tests, discussions, etc. R = Documentation Review: Review of medical record documentation, written report, written plans, etc. V = Verbal or other methods as appropriate and applicable."

The DOICA form for a Mental Health Technician listed the criteria facility staff utilized to evaluate a person on orientation. The criteria include: Safety, Department Practices, Customer Service, Basic Patient Safety, Resources, Patient Care, Code, Communicated Accurately and Concisely Patient's Status and Signs of Abuse and Neglect.

Review of PF1 (EMP14) on July 5, 2017, revealed the facility hired PF1 as a Mental Health Technician. PF1 was scheduled for orientation on May 3, 2017.

Interview with EMP12 on July 5, 2017, at approximately 10:30 AM confirmed the facility hired PF1 and the facility scheduled this employee's orientation for May 3, 2017.

Review on July 5, 2017, of the facility provided staff schedule for May 3 to June 10, 2017, revealed PF1 was on orientation from May 30 to June 9, 2017.

Interview with EMP4 and EMP7 on July 5, 2017, at approximately 11:00 AM confirmed PF1 was on orientation from May 30 to June 9, 2017.

Review on July 5, 2017, of the facility provided staff schedule for June 10 to July 8, 2017, revealed PF1 worked on a patient care unit on June 12, 13. 14, 16, 17, 18, 22, 23, 24, 27, 28 and 29, 2017. There was no indication on this staff schedule that PF1 was on orientation.

Interview with EMP4 on July 5, 2017, at approximately 1:30 PM confirmed PF1 worked on a patient care on June 12, 13. 14, 16, 17, 18, 22, 23, 24, 27, 28 and 29, 2017. EMP4 confirmed PF1 was no longer on orientation on these dates and performed tasks independently.

Review of PF1 on July 6, 2017, revealed no documentation the facility initiated the DOICA Mental Health Technician competency form.

Interview with EMP12 on July 6, 2017, at approximately 10:30 AM confirmed the facility did not initiate the DOICA Mental Health Technician competency form and there was no documentation or documented observation of PF1's performance while on orientation.

Interview with EMP4 on July 5, 2017, at approximately 2:00 PM confirmed the facility did not complete the DOICA Mental Health Technician competency form for PF1, and there was no documentation or documented observation of PF1's performance while on orientation.

Interview with EMP4 on July 6, 2017, at approximately 11:15 AM revealed the facility does not have a method or program in place to preceptor a person while on orientation. EMP4 confirmed a new employee performance was not assessed by direct observation by a supervisor, designated evaluator, preceptor or team member. EMP4 revealed the DOICA competency form was completed with the nurse manager of the unit and the person on orientation close to the 90th day by sitting down and covering the orientation criteria.

Cross reference:
482.13(c)(2) Patient Rights: Care in Safe Setting

Based on review of facility documents, medical records (MR), and staff interview, it was determined the facility failed to complete a nursing discharge note on a patient that was medically discharged from the facility for one of one medical records reviewed (MR1.)

Findings include:

Review on July 6, 2017, of the facility policy "Nursing Clinical Documentation," dated last revised March 2016, revealed "Policy: The nursing staff will document patient care activities in the patient record by completing required narrative notes and specific clinical chart forms. Purpose: 1. To communicate between and among patients care providers about the patient's status. 2. To document information necessary for continuity of care. 3. To provide a concurrent permanent legal record of the patient's hospitalization. Procedure/Guidelines For Narrative Progress Notes: . ... I. Types of Nursing Documentation: . ... 5. Nursing Discharge Note: Completed by a Registered Nurse or LPN when a patient is discharged/transferred to another facility. Time, level, and any pertinent information not noted on nursing discharge summary should be included. ..."

Review on July 5, 2017, of MR1 revealed a transfer order dated June 29, 2017. There was a Medical Discharge Form with a discharge date as June 29, 2017. The form stated the patient was transferred to and outside hospital. The form was not signed by a Registered Nurse, dated, or timed. No nursing discharge note was completed in MR1 regarding the reason for the discharge of the patient from the facility.

Interview on July 5, 2017, with EMP4 confirmed a transfer order dated June 29, 2017 and a Medical Discharge Form in MR1 with a discharge date as June 29, 2017. EMP4 confirmed the form was not signed by a Registered Nurse, dated, or timed.

Interview on July 6, 2017, with EMP1 confirmed no nursing discharge note was completed in MR1 regarding the reason for the discharge of the patient from the facility.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure plastic bags were not accessible to patients on the Adult 1 and Adult 3 patient care units.

Findings include:

Review on June 30, 2017, of the facility's "The Therapeutic Environment Focus: Containment" power point presentation, last revised January 19, 2017, revealed "Definitions: Therapeutic environment (milieu) describes an environment designed to help patients replace inappropriate behaviors with more effective personal and psychosocial skills. ... Focus: Containment Emphasis is on establishing a safe and secure environment that will protect the patient from self-harm or from intolerable environmental stresses. Keeping our patients safe is our First responsibility. Safety includes infection control practices, preventing accidents, legal documentation, and a safe and secure environment. ... Environmental Safety continued Observe for ligature risks every shift: Use shower hose only with staff present at all times. Lock shower hose in nursing station when not in use. Remove belts, shoelaces, drawstrings, plastic bags from patients. Everyone should observe for potential ligature risks and report using chain of command ..."

1) Observation on June 30, 2017, at 2:30 PM revealed EMP13 entered the Adult 3 patient care unit carrying a plastic bag and stool with two steps. EMP13 entered patient room 332 where MR8 and MR9 were resting in bed. EMP13 placed the stool on the floor in front of the window, opened the plastic bag, pulled out the window curtain, and proceeded to hang the window curtain. The plastic bag fell to the floor and was out of EMP13's line of vision.

Interview with EMP13 on June 30, 2017, at the time of the observation confirmed this employee entered the Adult 3 patient care unit carrying a plastic bag and stool with two steps. EMP13 entered patient room 332 where MR8 and MR9 were resting in bed. EMP13 placed the stool on the floor in front of the window, opened the plastic bag, pulled out the window curtain, and proceeded to hang the window curtain. The plastic bag fell to the floor and was out of EMP13's line of vision.

Interview with EMP5 on June 30, 2017, at the time of the observation confirmed EMP13 entered the Adult 3 patient care unit carrying a plastic bag and stool with two steps. EMP13 entered patient room 332 where MR8 and MR9 were resting in bed. EMP13 placed the stool on the floor in front of the window, opened the plastic bag, pulled out the window curtain, and proceeded to hang the window curtain. The plastic bag fell to the floor and was out of EMP13's line of vision. EMP5 confirmed the plastic bag should not be out of a staff person's line of vision, and there should have been a second person securing the plastic bag while EMP13 hung the curtains.

2) Observation on June 30, 2017, at 2:45 PM of the Adult 1 patient care unit revealed a plastic bag containing MR4's clothing and belongings on the floor against the patient's bed.

Interview with EMP5 on June 30, 2017, at the time of the observation confirmed the plastic bag containing MR4's clothing and belongings on the floor against the patient's bed. EMP5 confirmed plastic bags containing patient clothing and belongings were not to be accessible in the patient rooms. EMP4 revealed plastic bags containing patient clothing and belongings were to be stored in a locked room on the unit.

Continuing deficiency cited during the Validation survey November 9, 2016.